CALIFORNIA - Pacificare Health Systems

PART A
70
How Your Behavioral
Health Care Benefits Work
3. Either (a) your PBHC Participating Provider
has recommended a treatment, drug, device,
procedure, or other therapy that he or she
certifies in writing is likely to be more beneficial
to you than any available standard therapies, and
he or she included a statement of the evidence
relied upon by the Participating Provider in
certifying his or her recommendation; or (b)
you, or your non-contracting physician who
is a licensed, board-certified or board-eligible
physician or provider qualified to practice in
the area of practice appropriate to treat your
condition, has requested a therapy that, based
on two documents from medical and scientific
evidence (as defined in California Health and
Safety Code Section 1370.4(d)), is likely to
be more beneficial for you than any available
standard therapy.
Such certification must include a statement of
the evidence relied upon by the physician in
certifying his or her recommendation. PBHC
is not responsible for the payment of services
rendered by Non-Contracting Providers that are
not otherwise covered under the Member’s PBHC
benefits; and
4. A PBHC Medical Director (or designee)
has denied your request for a drug, device,
procedure, or other therapy recommended or
requested pursuant to paragraph (3); and
5. The treatment, drug, device, procedure, or other
therapy recommended pursuant to paragraph
3, above, would be a Covered Service, except
for PBHC’s determination that the treatment,
drug, device, procedure, or other therapy is
experimental or investigational. Independent
Medical Review for coverage decisions regarding
Experimental or Investigational therapies will
be processed in accordance with the protocols
outlined under “Independent Medical Review
Involving a Disputed Health Care Service” section
of this Evidence of Coverage.
Please refer to the “Independent Medical Review of
Grievances Involving a Disputed Health Care Service”
section found later in this Combined Evidence of
Coverage and Disclosure Form for more information.
What To Do If You Have a Problem
Our first priority is to meet your needs and that
means providing responsive service. If you ever have a
question or problem, your first step is to call the PBHC
Customer Service Department for resolution.
If you feel the situation has not been addressed to your
satisfaction, you may submit a formal complaint within
180 days of your receipt of an initial determination
over the telephone by calling the PBHC toll-free
number at 1-800-999-9585. You can also file a
complaint in writing:
PacifiCare Behavioral Health of California, Inc.
Post Office Box 55307
Sherman Oaks, CA 91413-0307
Attn: Appeals Department
Or at the PBHC Web site: www.pbhi.com
Appealing a Behavioral Health Benefit Decision
The individual initiating the appeal may submit
written comments, documents, records, and any
other information relating to the appeal regardless of
whether this information was submitted or considered
in the initial determination. The Member may
obtain, upon request and free of charge, copies of all
documents, records, and other information relevant to
the Member’s appeal. An individual who is neither the
individual who made the initial determination that is
the subject of the appeal nor the subordinate of that
person will review the appeal.
The PBHC Medical Director (or designee) will
review your appeal and make a determination within
a reasonable period of time appropriate to the
circumstances by not later than thirty (30) days after
PBHC’s receipt of the appeal, except in the case of
“expedited reviews” discussed below. For appeals
involving the delay, denial, or modifications of
Behavioral Health Services, PBHC’s written response
will describe the criteria or guidelines used and the
clinical reasons for its decision, including all criteria
and clinical reasons related to Medical Necessity.
For determinations delaying, denying, or modifying
Behavioral Health Services based on a finding that the
services are not Covered Services, the response will
specify the provisions in the plan contract that exclude
that coverage. If the complaint is related to quality
of care, the complaint will be reviewed through the
procedure described in the section of this Combined